RESUMO
OBJECTIVE: Food insecurity is associated with diabetes. The Supplemental Nutrition Assistance Program (SNAP) is the largest U.S. government food assistance program. Whether such programs impact diabetes trends is unclear. The objective of this study was to evaluate the association between changes in state-level policies affecting SNAP participation and county-level diabetes prevalence. RESEARCH DESIGN AND METHODS: We evaluated the association between change in county-level diabetes prevalence and changes in the U.S. Department of Agriculture SNAP policy index-a measure of adoption of state-level policies associated with increased SNAP participation (higher value indicating adoption of more policies associated with increased SNAP participation; range 1-10)-from 2004 to 2014 using g-computation, a robust causal inference methodology. The study included all U.S. counties with diabetes prevalence data available from the Centers for Disease Control and Prevention's U.S. Diabetes Surveillance System. RESULTS: The study included 3,135 of 3,143 U.S. counties. Mean diabetes prevalence increased from 7.3% (SD 1.3) in 2004 to 9.1% (SD 1.8) in 2014. The mean SNAP policy index increased from 6.4 (SD 0.9) to 8.2 (SD 0.6) in 2014. After accounting for changes in demographic-, economic-, and health care-related variables and the baseline SNAP policy index, a 1-point absolute increase in the SNAP policy index between 2004 and 2014 was associated with a 0.050 (95% CI 0.042-0.057) percentage point lower diabetes prevalence per year. CONCLUSIONS: State policies aimed at increasing SNAP participation were independently associated with a lower rise in diabetes prevalence between 2004 and 2014.
Assuntos
Diabetes Mellitus , Assistência Alimentar , Sistema de Vigilância de Fator de Risco Comportamental , Diabetes Mellitus/epidemiologia , Abastecimento de Alimentos , Humanos , Políticas , PobrezaRESUMO
BACKGROUND: Due to the high cost of left ventricular assist device (LVAD) therapy, payer type may be an important factor in determining eligibility. How payer type influences outcomes after LVAD implantation is unclear. We, therefore, aimed to study the association of health insurance payer type with outcomes after durable LVAD implantation. METHODS: Using STS-INTERMACS (Society of Thoracic Surgeons-Interagency Registry for Mechanically Assisted Circulatory Support), we studied nonelderly adults receiving a durable LVAD from 2016 to 2018 and compared all-cause mortality and postindex hospitalization adverse event episode rate by payer type. Multivariable Fine-Gray and generalized linear models were used to compare the outcomes. RESULTS: Of the 3251 patients included, 26.0% had Medicaid, 24.9% had Medicare alone, and 49.1% had commercial insurance. Compared with commercially insured patients, mortality did not differ for patients with Medicaid (subdistribution hazard ratio, 1.00 [95% CI, 0.75-1.34], P=0.99) or Medicare (subdistribution hazard ratio, 1.09 [95% CI, 0.84-1.41], P=0.52). Medicaid was associated with a significantly lower adjusted incidence rate (incidence rate ratio, 0.88 [95% CI, 0.78-0.99], P=0.041), and Medicare was associated with a significantly higher adjusted incidence rate (incidence rate ratio, 1.16 [95% CI, 1.03-1.30], P=0.011) of adverse event episodes compared with commercially insured patients. CONCLUSIONS: All-cause mortality after durable LVAD implantation did not differ significantly by payer type. Payer type was associated with the rate of adverse events, with Medicaid associated with a significantly lower rate, and Medicare with a significantly higher rate of adverse event episodes compared with commercially insured patients.
Assuntos
Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Coração Auxiliar/economia , Seguro Saúde , Medicare/economia , Adulto , Idoso , Feminino , Insuficiência Cardíaca/fisiopatologia , Hospitalização/economia , Humanos , Incidência , Seguro Saúde/economia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Estados UnidosRESUMO
[Figure: see text].
Assuntos
Injúria Renal Aguda , Estenose da Valva Aórtica , Cardiologia , Cirurgiões , Substituição da Valva Aórtica Transcateter , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/cirurgia , Mortalidade Hospitalar , Humanos , Incidência , Sistema de Registros , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: Thoracic endovascular aortic repair has been increasingly performed in higher-risk patients with renal failure. The objective was to compare Medicare patients with preoperative chronic kidney disease with patients with normal renal function to determine differences in postoperative survival and complications. METHODS: From 2000 to 2014, 27,079 Medicare fee-for service patients underwent thoracic endovascular aortic repair. Patients were stratified by kidney function, and 23,375 patients (86%) had no chronic kidney disease, 2957 patients (11%) had chronic kidney disease stage I/IV, and 747 patients (3%) had end-stage renal disease or hemodialysis. Groups were then compared with determined differences in adjusted all-cause mortality and rates of postoperative complications. RESULTS: Overall survival was significantly worse among patients with chronic kidney disease and end-stage renal disease or hemodialysis compared with patients with no chronic kidney disease (1-year survival no chronic kidney disease: 78%; chronic kidney disease I/II: 77%; chronic kidney disease III: 67%; chronic kidney disease IV: 58%; and end-stage renal disease or hemodialysis: 48%, P < .001). Mortality was significantly increased among patients with chronic kidney disease III (hazard ratio [HR], 1.29; P < .001), chronic kidney disease IV (HR, 1.74; P < .001), and end-stage renal disease or hemodialysis (HR, 2.03; P < .001). No mortality difference was found between patients with no chronic kidney disease and patients with chronic kidney disease stage I/II. At 30 days after thoracic endovascular aortic repair, sepsis was increased for patients with chronic kidney disease stage III/IV (HR, 1.7; P < .001) and end-stage renal disease or hemodialysis (HR, 2.7; P < .001). CONCLUSIONS: In this elderly Medicare population undergoing thoracic endovascular aortic repair, patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis had poor survival and increased morbidity compared with those with normal kidney function. These data may suggest that patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis should be more cautiously evaluated for thoracic endovascular aortic repair, weighing the benefits of the procedure against the high expected mortality.
Assuntos
Aneurisma da Aorta Torácica , Procedimentos Endovasculares , Medicare , Insuficiência Renal Crônica/complicações , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVES: Due to the scarcity of donor hearts to meet recipient demands, more than 40% of heart transplants are performed in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). The objective of this study was to determine the effect of BTT duration with an LVAD on posttransplant outcomes. METHODS: From 2009 to 2014, we identified 2639 fee-for-service Medicare patients who underwent a primary heart transplants with 1186 (45%) patients BTT with an LVAD. The LVAD patients were stratified as BTT ≤31 days (n = 28 [2.4%]), BTT 31-365 days (n = 748 [63.1%]), and BTT >365 days (n = 409 [34.5%]). Patients went directly to heart transplantation and were not bridged in 1453 cases (55%). LVAD duration was analyzed dichotomously and as a continuous variable with adjusted overall survival as the primary end point. RESULTS: All-cause mortality was significantly worse in patients who were BTT <31 days. Survival at 30 days was 81.5% for BTT <31 days, 94% for BTT 31 to 365 days, 95% for BTT >365 days, and 94% for no BTT. At 1 year, survival was 74% for BTT <31 days, 85% for BTT 31 to 365 days, 88% for BTT >365 days, and 89% for no BTT (P = .018). When LVAD duration was analyzed as a continuous variable, patients BTT with an LVAD <34 days had significantly increased mortality. CONCLUSIONS: Patients who underwent heart transplantation within the first month of BTT with an LVAD had significantly increased mortality. However, there was no survival difference among patients who were BTT with an LVAD longer than 31 days.
Assuntos
Transplante de Coração/métodos , Coração Auxiliar , Estudos Transversais , Feminino , Transplante de Coração/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Fatores de TempoAssuntos
Hospitalização/tendências , Unidades de Terapia Intensiva/tendências , Medicare/tendências , Distribuição por Idade , Idoso , Utilização de Instalações e Serviços , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Medicare/estatística & dados numéricos , Porto Rico , Distribuição por Sexo , Estados UnidosAssuntos
Cateterismo/tendências , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/tendências , Fatores Etários , Cateterismo/métodos , Cateterismo/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/epidemiologia , Terapia Trombolítica/métodos , Terapia Trombolítica/estatística & dados numéricosRESUMO
BACKGROUND: Scientific statements have championed the measurement of clinical outcomes after cardiac stress testing to better define their value. Using contemporary national data, we sought to describe the characteristics of patients who experience outcomes after stress testing. METHODS AND RESULTS: Using administrative claims from a large national private insurer, we conducted an observational cohort study of patients without cardiovascular disease aged 25 to 64 years who underwent stress testing from 2006 to 2011 and had at least 1 year of membership in the insurance company before and after testing. We used Kaplan-Meier time-to-event analyses to determine rates of acute myocardial infarction (AMI), elective coronary revascularization, and coronary angiography without revascularization in the year following testing. We used logistic regression to determine factors associated with outcomes, and stratified the cohort into quintiles based on likelihood of experiencing AMI and/or revascularization to describe the characteristics of patients at highest and lowest risk. Among 553 027 patients who underwent stress testing (mean age 50 years, 49% women, 73% white), 0.8% were hospitalized for AMI, 1.8% underwent elective coronary revascularization, and 2.5% underwent coronary angiography without revascularization within 1 year. Patients who were older, male, and white were more likely to undergo subsequent revascularization. Patients in the lowest likelihood quintile were young (mean age 40 years), frequently women (84.7%), had a low incidence of coexisting conditions (5.2% with diabetes mellitus), and had a 0.5% rate of AMI and/or revascularization. CONCLUSIONS: The proportion of US patients younger than 65 who had AMI and/or coronary revascularization after stress testing was low. Assessing risk of subsequent outcomes may be useful in improving patient referrals for stress testing.
Assuntos
Ecocardiografia sob Estresse/métodos , Eletrocardiografia/métodos , Teste de Esforço , Cardiopatias/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Tomografia Computadorizada de Emissão de Fóton Único , Demandas Administrativas em Assistência à Saúde , Adulto , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Bases de Dados Factuais , Feminino , Cardiopatias/epidemiologia , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Admissão do Paciente , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: To comprehensively evaluate and compare utilization, outcomes, and especially costs of transfemoral (TF), transapical (TA), and transaortic (TAO) transcatheter aortic valve replacement (TAVR). METHODS: All Medicare fee-for-service patients undergoing TF (n = 4065), TA (n = 691), or TAO (n = 274) TAVR between January 1, 2011, and November 30, 2012, were identified using Health Care Procedure Classification Codes present on Medicare claims. Hospital charges from Medicare claims were converted to costs using hospital-specific Medicare cost-to-charge ratios. RESULTS: TA and TAO patients were similar in age, race, and common comorbidities. Compared with TF patients, TA and TAO patients were more likely to be female and to have peripheral vascular disease, chronic lung disease, and renal failure. Thirty-day mortality rates were higher among TA and TAO patients than among TF patients (TA, 9.6%; TAO, 8.0%; TF, 5.0%; P < .001). Adjusted mortality beyond 1 year did not differ by access. TA patients were more likely to require cardiopulmonary bypass (CPB). Increased adjusted mortality was associated with CPB (hazard ratio, 2.13; P < .01) and increased 30-day cost ($62,000 [interquartile range (IQR)], $45,100-$86,400 versus $48,800 [IQR, $38,100-$62,900]; P < .01). Cost at 30 days was lowest for TF ($48,600) compared with TA ($49,800; P < .01) and TAO ($53,200; P = .03). CONCLUSIONS: For patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative and 1-year survival, except for higher rates of CPB use in TA patients. CPB was associated with worse survival and increased costs.
Assuntos
Estenose da Valva Aórtica , Cateterismo Periférico , Artéria Femoral/cirurgia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Aorta/cirurgia , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Cateterismo Periférico/métodos , Cateterismo Periférico/estatística & dados numéricos , Custos e Análise de Custo , Feminino , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Análise de Sobrevida , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/economia , Substituição da Valva Aórtica Transcateter/métodos , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Variability in the duration of attempted inhospital cardiopulmonary resuscitation (CPR) is high, but the factors influencing termination of CPR efforts are unknown. METHODS AND RESULTS: We examined the association between patient and hospital characteristics and CPR duration in 45 500 victims of inhospital cardiac arrest who did not experience return of spontaneous circulation (ROSC) and who were enrolled in the Get With the Guidelines registry between 2001 and 2010. In a secondary analysis, we performed analyses in 46 168 victims of inhospital cardiac arrest who experienced ROSC. We used ordered logistic regression to identify factors associated with CPR duration. Analyses were conducted by tertile of CPR duration (tertiles: ROSC group: 2 to 7, 8 to 17, and 18 to 120 minutes; noROSC group: 2 to 16, 17 to 26, 27 to 120 minutes). In those without ROSC, younger age (aged 18 to 40 versus >65 years; odds ratio [OR] 1.81; 95% CI 1.69 to 1.95; P<0.001), female sex (OR 1.05; 95% CI 1.02 to 1.09; P=0.005), ventricular tachycardia or fibrillation (OR 1.50; 95% CI 1.42 to 1.58; P<0.001), and the need to place an invasive airway (OR 2.59; 95% CI 2.46 to 2.72; P<0.001) were associated with longer CPR duration. In those with ROSC, ventricular tachycardia or fibrillation (OR 0.89; 95% CI 0.85 to 0.93; P<0.001) and witnessed events (OR 0.87; 95% CI 0.82 to 0.91; P<0.001) were associated with shorter duration. CONCLUSIONS: Age and sex were associated with attempted CPR duration in patients who do not experience ROSC after inhospital cardiac arrest but not in those who experience ROSC. Understanding the mechanism of these interactions may help explain variability in outcomes for inhospital cardiac arrest.
Assuntos
Circulação Sanguínea , Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Pacientes Internados , Ordens quanto à Conduta (Ética Médica) , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Taquicardia Ventricular/complicações , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Fibrilação Ventricular/complicações , Adulto JovemRESUMO
BACKGROUND: In-hospital cardiac arrest (IHCA) is common and often fatal. However, the extent to which hospitals vary in survival outcomes and the degree to which this variation is explained by patient and hospital factors is unknown. METHODS AND RESULTS: Within Get with the Guidelines-Resuscitation, we identified 135 896 index IHCA events at 468 hospitals. Using hierarchical models, we adjusted for demographics comorbidities and arrest characteristics (eg, initial rhythm, etiology, arrest location) to generate risk-adjusted rates of in-hospital survival. To quantify the extent of hospital-level variation in risk-adjusted rates, we calculated the median odds ratio (OR). Among study hospitals, there was significant variation in unadjusted survival rates. The median unadjusted rate for the bottom decile was 8.3% (range: 0% to 10.7%) and for the top decile was 31.4% (28.6% to 51.7%). After adjusting for 36 predictors of in-hospital survival, there remained substantial variation in rates of in-hospital survival across sites: bottom decile (median rate, 12.4% [0% to 15.6%]) versus top decile (median rate, 22.7% [21.0% to 36.2%]). The median OR for risk-adjusted survival was 1.42 (95% CI: 1.37 to 1.46), which suggests a substantial 42% difference in the odds of survival for patients with similar case-mix at similar hospitals. Further, significant variation persisted within hospital subgroups (eg, bed size, academic). CONCLUSION: Significant variability in IHCA survival exists across hospitals, and this variation persists despite adjustment for measured patient factors and within hospital subgroups. These findings suggest that other hospital factors may account for the observed site-level variations in IHCA survival.